Past Medical History

Patient Name

First NameLast Name

Patient Date of Birth

Date

Have you been previously diagnosed with a medical condition(s)? Please list each one.

What surgical or medical procedures have you had in the past?

Please tell us about medical conditions in your family including cancer, diabetes, heart disease, etc., and at what age they developed the disease. Limit answers to father, mother, and siblings.

Have you undergone current or recent hormone therapy - if yes, specify type and duration.

Have you been tested for or diagnosed with obstructive sleep apnea? Do you currently use a CPAP machine or other related therapy?

What medications, herbs, and vitamins/ supplements are you currently taking? Remember to include over-the-counter medicines. Please include the doses and how often you take each one. If the list is too long for this field you can email us directly.

Please list known allergies and type of reaction to each.

Please indicate if any of the following apply to you:

Rows	Yes	No
Unstable Angina, Stroke, or Hearth Attack in last 6 months
History of Severe Bipolar Disorder, Depression, or Psychosis
History of Uncontrolled Seizures
Past or Present Cancer Diagnosis
Active Colitis
Extreme Adrenal Fatigue
Cholelithiasis or Pancreatitis
Renal Stones
Currently Pregnant
Diabetes
DVT or Pulmonary Embolism
Other

If you indicated yes above, please explain your answer:

How often have you experienced the following over the last month?

Rows	Never	Weekly	Daily	Every Day
Anxiety
Depression
Panic Attacks
Suicidal Ideation

Weekly exercise?

Sleep quality?

Weekly alcohol consumption?

Caffeine consumption?

Do you smoke Tobacco or use other Nicotine products?

Do you smoke Marijuana or use other THC products?

Do you have any other comments not adressed in any of the questions prior?

By signing below, I certify that I have filled out this form truthfully and am not withholding any information about my current or past medical history.

Name

First NameLast Name

Relationship to the patient

Signature

Past Medical History

Patient Information